Endovascular Retrieval Research Articles

PC216. Ultrasound-Assisted Retrieval of Embolized Femoral Arterial Catheter

Intravascular foreign body embolization as a result of catheter fracture is a rare but serious event that most often requires retrieval. Whereas many instances of central venous catheter fractures have been reported, arterial catheter fracture with embolization has rarely been described. Herein, a successful ultrasound-assisted endovascular retrieval of a fractured femoral arterial line catheter using a three-lobe snare is illustrated (Figs 1 and 2). After retrieval, there were excellent femoral and pedal pulses. Doppler flow through the vessels was normal, and the patient was discharged without further vascular complications. Considering the potential risks of vessel obstruction, thrombosis, end-organ ischemia, and perforation, arterial foreign bodies should generally be retrieved. However, there are many considerations in such endeavors that need to be contemplated, including location and associated symptoms, procedural techniques, and optimal imaging tools to locate and help in the extraction of the foreign body. In this case report, an ultrasound-assisted endovascular retrieval of a fractured femoral arterial catheter from the iliac artery is presented and discussed.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)

A case report: X-linked dystrophin gene mutation causing severe isolated dilated cardiomyopathy

Background X-linked dilated cardiomyopathy (XLDCM) is a rare but rapidly progressive cardiomyopathy caused by dystrophin gene mutation. Mutations are more often associated with Duchenne and Becker Muscular Dystrophy, which are characterized by skeletal muscle weakness or limb girdle dystrophy. However, patients with isolated XLDCM have normal skeletal muscle but complete dystrophin loss in cardiac muscle resulting in isolated myocardial involvement without overt signs of skeletal myopathy.Case summary A previously well 16-year-old boy developed sudden onset dense left-sided weakness and facial droop. Computed tomography (CT) angiography and CT brain showed an occluded right internal carotid artery extending to the right middle cerebral artery. He underwent successful endovascular clot retrieval but developed frank pulmonary oedema and cardiogenic shock requiring inotropic support and intubation. Transthoracic echocardiography demonstrated severe left ventricular (LV) cardiomyopathy and an apical thrombus. Subsequent cardiac magnetic resonance (CMR) imaging confirmed the LV parameters and diffuse late gadolinium enhancement. Despite absence of skeletal manifestations, subsequent genetic testing revealed an X-linked dystrophin gene mutation [c.31+G>T (IVS1G>T)]. He was commenced on empirical heart failure therapy and underwent successful cardiac transplantation.Discussion X-linked dilated cardiomyopathy is a rare, rapidly progressing cardiomyopathy. Patients show normal skeletal muscle dystrophin but absent expression in cardiac muscle, resulting fibrosis, and atrophy. About 20% of affected young males have significantly reduced survival and thus the diagnosis must be considered in cases of idiopathic cardiomyopathy with CMR and genetic testing key to the diagnosis. Whilst evidence exists for empirical heart failure medications, cardiac transplantation remains the definitive treatment.

Retrieval of Inferior Vena Cava Filters Temporarily Placed in a Suprarenal Position: A Review of 13 Patients.

To evaluate the safety and efficacy of retrieval of inferior vena cava filters (IVCF) temporarily placed in a suprarenal position. Retrieval of IVCF placed in a suprarenal position was performed in 13 patients (5 men and 8 women; mean age: 45.1 ± 13.8 years) between July 2006 and May 2018 using either a loop snare technique or endobronchial forceps. Electronic medical records were reviewed for patient demographics and procedural information. Inferior vena cava filters retrieved included Option Elite (n = 9, 69%) and Günther Tulip (n = 4, 31%). Caval thrombosis was not detected in any patients on pre- or postretrieval cavogram. Eleven suprarenal IVCF (84%) were retrieved during the first retrieval attempt after a median indwelling time of 1.8 months (range, 0.03-12.10 months). Retrieval was initially unsuccessful in 2 (16%) patients with Option Elite filters, but both were successfully removed on second attempt using endobronchial forceps. Thirteen suprarenal IVCF (100%) were ultimately retrieved. Endovascular retrieval of IVCF temporarily placed in a suprarenal position is safe and efficacious.

Stroke Prehospital Informed Decision-Making Using EEG Recordings (SPIDER)

Introduction:The acute care of stroke involves the administration of a clot-dissolving drug (thrombolysis) and/or its removal using endovascular clot retrieval. Earlier intervention results in significantly improved patient outcomes. Clinical assessment scores have limitations, and studies have shown that even the most robust scores have a reported false-negative rate of >20% for large vessel occlusive strokes that may be eligible for clot retrieval, while inappropriate bypass may delay delivery of thrombolysis.1 Quantitative Electroencephalography (QEEG) has been shown to have a very high sensitivity and specificity in the identification of acute stroke versus matched controls in an in-hospital setting.(2,3)Aim:The SPIDER study commenced in Brisbane, Queensland on September 3, 2018, and is investigating the use of an EEG recorder to gather data on acute stroke patients presenting to a metropolitan ambulance service.Discussion:The data collected will guide the development of a simple numerical output reference to guide decision making. The data may aid in identifying large vessel occlusive stroke and patients eligible for endovascular intervention. The QEEG will provide a more accurate and cost-effective tool for the prehospital clinician over other imaging technologies and can guide early destination decisions. This presentation discusses the implementation of a pre-hospital research platform, integration with the clinical dispatch matrix, staff engagement, patient recruitment, and the success of the project so far.

Percutaneous retrieval of an embolized gunshot bullet from right ventricle: a case report and review of literature.

BackgroundGunshots embolizing to the heart is a rare occurrence. We report a case of percutaneous retrieval of a gunshot bullet from the right ventricle (RV) cavity of a 40-year-old lady. To the best of our knowledge, this is the first case to be reported with a right supraclavicular inlet of the bullet and successful percutaneous retrieval using a snare from the RV cavity.Case summaryA 40-year-old female patient was referred to our cardiac centre from a general hospital with a gunshot injury 8 days prior. On arrival, she was haemodynamically stable, there was an inlet wound at the right supraclavicular area. Transthoracic echocardiography revealed the bullet in the RV cavity. Under conscious sedation, right femoral vein access succeeded to retrieve the shot from the RV to the groin. The bullet slipped out and resnared from the right internal iliac vein and came out safely from the right femoral vein through the 24-Fr sheath. The vein was closed using a figure of 8 suture. The patient discharged home after 2 days.DiscussionBullet emboli to the heart are rare, endovascular retrieval of a bullet from the right ventricular cavity is feasible and relatively safe; however, more research is required. Echocardiography during the procedure is strongly recommended to early detect any complications. Accurate use of available tools such as X-ray, echocardiography, computed tomography, and fluoroscopy is a must for precise diagnosis.

Acute middle cerebral artery stroke in a patient with a patent middle cerebral artery.

Knowledge of cerebrovascular anatomical variants is vital for clinicians working with patients presenting with signs and symptoms of cerebral infarction, particularly in the era of endovascular clot retrieval. We provide an overview of a cerebrovascular anatomical variation and detail a patient presenting with cerebral infarction secondary to occlusion of their anomalous vessel who underwent successful endovascular clot retrieval with excellent functional outcome. We also include technical descriptions. Given the clinical importance of the areas supplied by the accessory middle cerebral artery, knowledge of this vessel is not only important for diagnosis but also for neurosurgical or endovascular management of patients with this variant.

Googling Boundaries for Operating Mobile Stroke Unit for Stroke Codes.

Background: Mobile stroke units (MSU) have been proposed to expedite delivery of recombinant tissue plasminogen activator (tPA) and expedite endovascular clot retrieval (ECR). Unexplored questions in the use of MSU include: maximal distance from base, time limit with regards to the use CT imaging, CT Angiography, CT Perfusion, and Telemedicine. We developed a computational model as an app (https://gntem3.shinyapps.io/ambmc/), taking into account traveling time to explore this issue. The aim of this study was to define the operating parameters for an MSU in a large metropolitan city, based on the geography of Melbourne.Methods: There are 2 hospitals (Royal Melbourne Hospital/RMH, Monash Medical Center/MMC) designated to provide state-wide ECR services. In these spatial simulations, the MSU is based at RMH and delivers tPA at the patient's pick-up address and then takes the patient to the nearest ECR center. We extracted the geocode of suburbs in Melbourne and travel time to each hospital using ggmap, an interface to Google Map API. The app contains widgets for varying the processing time at the patient location (default = 30 min), performing CT angiography (default = 10 min), performing telemedicine consultation (default = 15 min). The data were compared against those for usual ambulance metrics (default traveling time = 15 min, processing time at patient's location = 20 min, door to tPA = 60 min, door to groin = 90 min). Varying the widgets allow the viewer to explore the trade-off between the variable of interest and time to therapy at a suburb level.Results: The MSU was superior for delivering tPA to all Melbourne suburbs (up to 76 min from RMH). If the CTA times or processing time at location increased by 20 min then it was superior for providing ECR to only 74.9% of suburbs if the return base was RMH. Addition of CT Perfusion or telemedicine consultation affect the ability of a single hospital to provide ECR but not tPA if these additions can be limited to 20 min. Conclusion: The app can help to define how best to deploy the MSU across Melbourne. This app can be modified and used to optimize operating characteristics of MSU in other centers around the world.

Endovascular clot retrieval in acute stroke with large ischaemic core is not always associated with poor outcomes.

The benefits of endovascular clot retrieval (ECR) for anterior circulation stroke with large ischaemic cores remain uncertain. In spite of recent pooled analysis of randomised controlled studies, conclusions regarding the fate of large ischaemic cores cannot be reached given the small number of included patients. To evaluate outcomes of ECR in acute stroke with large ischaemic core. This was a single centre retrospective study of patients treated with ECR in the period 2012-2017. The inclusion criteria were anterior circulation stroke with symptom onset less than 6 h, baseline computed tomography perfusion and a 90-day clinical follow up defined by the modified Rankin score. Two hundred and sixty-one patients were included. Median age of 72 (interquartile range: 61-78) and 59% were male. The mean ischaemic core volume was 27.6 mL (SD: 34.9 mL). There were 235 patients with an ischaemic core volume of <70 mL and 26 patients with an ischaemic core volume of ≥70 mL. There was no statistically significant difference; however, in a 90-day functional independence with 66% (154/235) in the <70 mL core group and 54% (14/26) in the ≥70 mL core group reaching a 90-day modified Rankin score ≤2. We found that patients selected for ECR with ischaemic core size ≥70 mL had clinical outcomes not significantly different compared with those with smaller ischaemic cores. We recommend that large ischaemic core size alone does not necessarily constitute an absolute contraindication for ECR. Randomised controlled studies are needed to define better the benefits for this group of patients.

03:18 PM Abstract No. 191 Endovascular management of fractured inferior vena cava filter fragments: a 10-year single-center experience

Fracture is a known adverse event (AE) associated with inferior vena cava filters (IVCF). There has been growing interest in endovascular retrieval of IVCF fragments; however, this carries risks including migration with procedural manipulation. We aim to describe the management of fractured IVCF from a single center specializing in advanced filter retrieval. A prospective database collected from 2008 to 2018 was reviewed for IVCF fracture in which endovascular retrieval was attempted. We assessed patient age, sex, dwell time, fragment location, and device-related (categorized as major if surgical removal required)/procedure-related AEs (categorized per SIR guidelines). Fifty-three patients (35 females, mean age 49) with 98 fragments were identified. The median dwell time was 6 years (range 0.2-2). Attempted retrieval of 53 fragments yielded a 70% success rate, and were located as follows: 44 IVC, 1 hepatic vein, 1 renal vein, 3 pulmonary, 1 aorta, 2 cardiac and 1 unknown. Intraprocedural migration occurred 9 times with 3 immediately retrieved; 2 stayed within the IVC, 3 to lung, 1 to right ventricle, 1 to an iliac vein, 1 to the aorta via a patent foramen ovale, 1 not found on subsequent imaging. Forty-five fragments were extravascular; no endovascular retrieval attempt was made and these were located as follows: 15 pericaval fat, 9 lumbar spine, 8 pulmonary, 7 cardiac, 3 psoas, and 3 hepatic parenchyma. Three cardiac fragments were retrieved surgically: a migrated fragment in the right ventricle and known fragments in the tricuspid annulus and right ventricular wall. The remainder were retrieved via an endovascular approach. There was a 12% device-related/15% procedure-related AE rate. The major device-related AE were the two known cardiac fragments causing arrhythmia and pericardial tamponade. The major procedure-related AE was the embolized intra-procedural fragment to the heart. While technically feasible, IVCF fragment retrieval carries a risk of migration due to procedural manipulation; migration to the heart may necessitate surgical intervention. Fragment retrieval should be considered on an individualized basis, after a thorough discussion of the risks.

Abstract No. 597 Endovascular retrieval of Greenfield vena cava filters: a multicenter 5-year experience

Abstract No. 597 Endovascular retrieval of Greenfield vena cava filters: a multicenter 5-year experience

Abstract 88: Decrease in Stroke Mortality With Increase in Rate of Thrombectomy in Acute Ischemic Stroke in Nationwide Inpatient Sample

Background: Endovascular Thrombectomy was shown to be effective in treatment of Acute Ischemic Stroke (AIS) in series of clinical trials in 2015, prior to that there were neutral trials. We looked at National inpatient sample to see the trends in Thrombectomy and outcomes after the publication of clinical trials. Methods: Using the National Inpatient Sample, we evaluated outcomes of patients treated for AIS in the United States from first 9 months of 2013 and compared them to first 9 months of 2015 due to ICD 9 to 10 migration. Patients who had AIS and underwent endovascular clot retrieval were identified. Morbidity and mortality were evaluated as a function of patient age and of concomitant thrombolytic agent administration. We compared the rates of thrombectomy done before the clinical trials were published to the time after the clinical trials were published. Results: In 2013, there were 4,700 (15.6%) reported thrombectomies from 30,160 treated patients, as compared to 8,880 (22.3%) in 2015 from 39,795 treated patients. This increase was statistically significant (p&lt;0.0001) and indicated almost doubling of raw numbers of thrombectomies. Multivariable analysis showed statistically significant decrease in adjusted risk of mortality (aOR, 95%CI = 0.81(0.71-0.92), p=0.002) see figure 1. The comorbidities as measured by Charlson’s Comorbidity index remained unchanged 7.2±2.6 vs 7.3±2.7 (p=0.22). Unadjusted mortality rate significantly decreased from 17.2% in 2013 to 15.2% in 2015 (p&lt;0.002). Complication rates and median length of stay (LOS) were similar in the two time periods 42% vs 41.3% and 7 (4-12) vs 6 (4-11) days, respectively. Chance of having thrombectomy was 50% higher in 2015 vs 2013 (aOR, 95%CI = 1.49 (1.35-1.64), p&lt;0.0001). Rates of IV t-PA administration as a control did not change 3.1 vs 3.2%. Conclusions: The OR of having thrombectomy for AIS patient increased by 50% from 2013 to 2015 and led to improved outcomes including lower mortality.

Validated Pre-Hospital Stroke Scales to Predict Large Vessel Occlusion: A Systematic Review

Background Occlusions of large cerebral vessels, including the internal carotid artery and middle cerebral artery, result in significant burden of morbidity. Treatment was previously limited to intravenous thrombolysis, however multiple studies have shown significant improvements when patients undergo endovascular clot retrieval. Early identification and triage to centres capable of delivering this is likely to contribute to improved outcomes. This systematic review aims to compare clinical assessment tools and their performance ‘in-field’ to identify usability and reliability to assist pre-hospital providers with identification of this sub-group of stroke patients. Methods Several databases were reviewed to identify studies that have validated large vessel occlusion clinical assessment tools within the pre-hospital environment. Sensitivity, specificity and predictive value were compared along with any biases. Six studies met the study criteria and were included. A total of 1384 patients were involved in the studies with sensitivities ranging from 51.9% to 100% and specificities ranging from 68% to 90%. Conclusion There is significant variation among studies and the emergency medical systems they have been performed within. It is likely that no single tool will suit every system and further research is required to determine the best tool for the Australian pre-hospital environment.

Endovascular retrieval of fractured chemoport at the superior vena cava-right atrial junction in 3 years old

A 3-year-old female child, a case of lymphoid leukemia successfully completed her last cycle of chemotherapy. While retrieving the chemoport, the distal part of the port was fractured and migrated distally in the superior vena cava which was seen on the chest radiograph and later confirmed on computed tomography (scan). We present an interesting case where removal of such a fractured port segment was done in toto by means of endovascular intervention through the common femoral vein under fluoroscopy guidance.

Endovascular Retrieval of Dislodged Neurovascular Devices with a Stentriever: Case Series and Technical Review

Endovascular treatment of neurovascular disorders is now well established as effective and safe; however, the nature of the intracranial vasculature poses unique challenges. The unintentional dislodgement or fracture of a device and its migration within cerebral vessels is a complication with serious potential morbidity that must be managed urgently. In this series, the authors describe 7 cases of a stentriever being used to remove foreign objects from within the cerebral vasculature. A retrospective search of all interventional neurovascular procedures performed in 2017 at a tertiary metropolitan hospital was performed to identify cases of dislodged devices. Five dislodged endovascular coils, 1 microcatheter, and 1 fractured stentriever were technically successfully retrieved. In 6 of the cases, the foreign object was successfully removed with a stentriever alone, whereas 1 case used a J-tip wire and a "J-tip flick" to manipulate the coil and facilitate retrieval. Stentrievers, particularly when used alone, confer the advantages of speed, cost, as well as being tailor-made for cerebral vessels. They also allow continuous blood flow when deployed, a critical advantage when considering cerebral perfusion. Critical techniques include the gradual deployment of the stentriever alongside the foreign object to allow its entanglement and partial resheathing, so that the foreign object can become pinned within the microcatheter. Stentrievers do remain limited by vessel caliber and are less able to entangle larger, stiffer devices. The migration of foreign devices during neurointerventional procedures is a serious complication requiring urgent treatment. This case series highlights the efficacy and advantages of using a stentriever and suggests its consideration as a first-line technique in recovering dislodged foreign bodies in the cerebral vasculature.

Endovascular Clot Retrieval by Hub-and-Spoke Service Delivery is Feasible Compared with Direct-to-Mothership

Background: Endovascular clot retrieval (ECR) improves outcomes for acute ischaemic stroke with large artery occlusion. However, the provision of ECR requires resource-intensive comprehensive stroke centres (CSC), which are impractical to establish in regional hospitals. An alternative is a “hub-and-spoke” model, whereby ischaemic strokes are triaged at the regional primary centres and where eligible, transferred to a CSC. We aimed to compare the outcomes of patients directly admitted to a CSC with patients treated in the “hub-and-spoke” model. We hypothesize that there are no significant differences in clinical outcomes between the 2 systems. Methods: We included patients undergoing ECR at a CSC. Patients were categorised into 2 groups; the first group included patients directly admitted to the CSC and the second group included patients in the “hub-and-spoke” model. Good clinical outcome was defined as modified Rankin Scale 0–2 and the difference between the 2 groups was tested by logistic regression. Results: Of 178 patients, 50 (28%) presented directly to CSC and 128 (72%) were transferred from a referring hospital. The median age was 70 (interquartile range 58–77) and 61% were male. Thrombolysis in ischaemic cerebral-infarction 2b/3 recanalisation was achieved in 79% of patients. Of the direct group, 63% (95% CI 48–77%) achieved good clinical outcomes compared to 52% (95% CI 43–61%) in the “hub-and-spoke” group (p = 0.233). Conclusion: This state-wide service model demonstrates comparable clinical outcomes to that described in clinical trials. We found no significant difference in outcome between patients directly admitted to CSC and those with “hub-and-spoke” service delivery.

Snaring of a Glued Microcatheter During Embolization of an Arteriovenous Malformation with N-Butyl Cyanoacrylate

Microcatheter entrapment during embolization of brain arteriovenous malformations (AVMs) represents a potentially harmful technical complication. Although several techniques have been reported for endovascular catheter retrieval from an Onyx cast, such methods have never been demonstrated with acrylic glues. We report a case of removal of a glued microcatheter from an N-butyl cyanoacrylate (NBCA) cast using a microsnare. A 26-year-old woman presented with an intracranial hemorrhage resulting from a ruptured right choroidal AVM. A microcatheter used for transarterial embolization was unintentionally glued into the NBCA cast. Because attempts to remove the catheter by simple traction failed, a microsnare was used and allowed withdrawal of the entrapped microcatheter without causing damage to the cerebral vasculature. The patient woke up without clinical sequelae. Although it is not recommended as routine practice, snaring a glued microcatheter is feasible and can be used in selected cases as a last resort if thromboembolic complications are feared.

Successful surgical retrieval of Celt ACD\xae vascular closure device embolised in the tibioperoneal trunk

BackgroundThis report presents a case of surgical retrieval of a Celt ACD® vascular closure device (VCD) situated in the tibioperoneal trunk, following a failed attempt at deployment. Existing literature mostly recommends an endovascular approach when attempting to retrieve embolised VCDs.Case presentationA 55 year old male presented with right sudden right lower limb pain and numbness 1 week following a successful left retrograde superficial femoral artery (SFA) angioplasty. Computed tomography (CT) angiogram revealed that the Celt ACD® VCD had embolised in the right tibioperoneal trunk. An endovascular approach was initially attempted to retrieve the VCD; however, this was unsuccessful due to the small diameter of the target artery. Due to the failure of the endovascular approach, surgical exploration of the right tibioperoneal trunk was undertaken, which led to the successful retrieval of the embolised VCD.ConclusionThe case presented herein demonstrates the critical need for swift and decisive surgical exploration of patients with suspected embolisation of Celt ACD® devices in smaller distal arteries. Our experience has led to the recommendation that, due to the sharp edges of the Celt ACD® accompanied with the small diameter of the occluded vessels, surgical exposure and retrieval is the safest option if endovascular retrieval is unsuccessful.

Endovascular Retrieval of an Embolized Atrial Septal Occluder Device From the Abdominal Aorta

Patent foramen ovale (PFO) is a common heart condition in adults. Closure with a septal occluder device is a safe, well-established treatment option with excellent clinical outcomes. One rare complication of percutaneous PFO closure is embolization of the device to the heart chambers or distal vasculature. Most device migrations are recognized during or shortly after implantation. While many endovascular retrievals of migrated devices are successful, there are still a high percentage of surgical interventions performed. We report a case of a septal occluder device that embolized to the abdominal aorta and was discovered 7 days after implantation. Endovascular techniques with a snare and endobronchial forceps were used to retrieve the device safely.

Endovascular Retrieval of Migrated Coil within the Distal Middle Cerebral Artery Using Stentriever Device

Displacement of endovascular coils during endovascular embolization of an intracranial aneurysm is a potentially life-threatening complication. Several methods for coil retrieval have been described, including the use of microsnares and microforceps retrieval devices. With the recent surge of stentriever implementation in the treatment of ischemic stroke, some operators are now using such devices in the retrieval of migrated coils. Wepresent a case of a balloon-assisted coil embolization of a communicating segment internal carotid artery aneurysm, complicated by coil migration far distally into the middle cerebral artery, which was retrieved successfully with a stentriever. To the best of our knowledge, this is the furthest migration of a coil to be successfully retrieved with a stentriever. We review conservative and invasive management of displaced coils and the technical advantages of stentrievers over retrieval devices. The patient's medical records were retrospectively reviewed, including clinical and radiographic information. This study received institutional review board approval. The patient was treated with balloon-assisted coil embolization of the internal carotid artery aneurysm. The migrated coil was retrieved successfully using a novel application of a stentriever. In certain situations, a stentriever does not mandate complete ensnaring of the target to be retrieved and thus need not always be deployed distal to a migrated coil mass to be successful. Due to the mechanical advantage of strut-engagement, stentrievers can afford to be positioned in relatively suboptimal positions, and this is especially useful in cases involving tortuous and small distal vessels (<2 mm diameter).

Phase 1 Trial of Amnion Cell Therapy for Ischemic Stroke.

There is increasing interest in stem cell therapy as another treatment modality in stroke, particularly for patients who are unable to receive endovascular clot retrieval or thrombolysis therapies, or for whom standard treatment has failed. We have recently shown that human amniotic epithelial cells (hAECs) are effective in reducing infarct volume in different animal models of ischemic stroke, including in non-human primates. hAEC therapy attenuated infarct growth and/or promoted functional recovery, even when administered 1-3 days after the onset of stroke. We now propose an open label Phase 1 dose escalation trial to assess the safety of allogeneic hAECs in stroke patients with a view to providing an evidence platform for future Phase 2 efficacy trials. We propose a modified 3 + 3 dose escalation study design with additional components for measuring magnetic resonance signal of efficacy as well as the effect of hAECs on immunosuppression after stroke. The trial will commence in 2018. The findings will be published in a peer-reviewed journal. The trial is registered with ANZCTR (ACTRN12618000076279p).